Saturday, April 30, 2005

The Unconscionable Clause

I'm sure you've read all the debates back and forth about Pharmacists and other healthcare providers not wanting to be involved in abortion, anything they consider to possibly impede implantation of a fertilized ova in a woman's uterus (ova+uterus=female) and anything else they consider to be related to sins of sexual immorality. Last night I posted about Colorado Gov. Bill Owen's veto of a bill that would ensure that rape victims were provided with all the health-care related information due them (including information on/access to emergency contraception or referral to someone who would) as should be required under law and the arguments that contraception (emergency and routine) causes sexual immorality and abortion. Today, this non-feminist took an electronic stroll over to Feministe to come across an interesting little tidbit about how Catholic Hospitals plan to treat rape victims.

Now I understand that the Catholic Church proscribes contraception (except natural family planning) with the belief that sex is a sacred act between a married couple with a primary (but not sole) purpose of procreation. Based on this, it makes perfect sense for Catholic Hospitals not to perform abortions except when a patient presents in an emergent situation with an ectopic pregnancy. It also makes sense that their pharmacies would not stock contraceptives, physicians would refrain from prescribing contraceptives (I'm not sure if they're permitted to prescribe them for treatment of endometriosis or to shrink an ovarian cyst); surgeons would not perform tubal ligations, or any form of hysterectomy on a woman that is not post-menopausal except to save the woman's life (i.e., uterine/ovarian cancer) and choices in fertility treatments would be limited.

In all of the aforementioned instances, Catholic Hospitals make certain exceptions in emergent situations. Oddly, the exception 6 Catholic hospitals in Colorado make in the case of rape is incomplete: physicians will be permitted (not required) to tell a victim/patient about emergency contraception and write a prescription (if asked by the victim/patient) if she has not yet ovulated; if she has ovulated, they are not permitted to discuss emergency contraception. This, one can assume, is based on a belief that contraceptives are abortifacients because they could possibly thin the endometrial lining making it less hospitable to implantation of a fertilized egg (more accurately, by implantation it's now 16 cells and called a blastocyst). The primary mechanism of action of emergency contraception (high dose progesterone) is the prevention of ovulation, so I am quite glad to see these hospitals allowing discussion of and access to EC for women who haven't ovulated (there are many "pro-lifers" who don't approve it's use at all). There are other suspected ancillary mechanisms of actions for contraceptives (it is not uncommon for a drug to be approved as safe and efficacious without the actual mechanism of action being known at all) that include creating an environment in the female genitourinary tract that is hostile to sperm or creates other barriers to fertilization if ovulation does occur. Another possible (tertiary) mechanism of action for some contraceptives may include making the uterus less hospitable to implantation because with chronic use, many women do experience lighter periods due to development of thinner endometrial linings (this is one reason women with endometriosis are prescribed hormonal contraceptives). Bear in mind, the implantation rate post conception is about 40-60% in the best of circumstances, so it's extremely difficult to determine if/when routine use of hormonal contraceptives causes a statistically significant decrease in the implantation rate. This being said, this is an unlikely mechanism of action for EC as the medication is acute use of high levels of progesterone (as I've mentioned in a few places, if a reproductive endocrinologist could correct me and/or clarify the situation, I'd greatly appreciate it). If the providers at these hospitals intentionally omit information about a treatment that could prevent fertilization, they're acting as a de facto agent of the rapist by prolonging the physical trauma and facilitating any resultant pregnancy. If the victim is not provided the information in time, becomes pregnant and decides to terminate, the providers (and the hospitals themselves) are responsible for the forcible creation of a child as well as its "murder" as a matter of policy.

Healthcare practitioners are held to a different standard than other professions for good reason. They are required to provide all reasonably relevant information and information about things that are rare but potentially serious/severe in nature to their patients (and/or their caregivers) to ensure they are adequately informed. As a healthcare provider, you are not permitted to omit information in discussions with patients because you don't approve of what they might do with that information. Patients (or their caregivers) must be able to make informed decisions and provide informed consent; full disclosure (including referral for additional opinions/treatments that may be different than what you think appropriate) is necessary for this to occur - anything else is malpractice. Just as a genetic counselor or OB does not have the right to omit pertinent information about potential treatments/therapies that may impact the decision a patient (mother/couple) makes when the provider believes termination of pregnancy is warranted but thinks the information might lead the patient to decide to continue the pregnancy, a provider does not have the right to withold pertinent information to a patient because that provider believes the patient would decide to terminate the pregnancy (because the provider thinks abortion is immoral).

In cases in which healthcare providers have conflicting interests, they are obligated to fully disclose this conflict of interest, provide factual information about alternatives and allow the patient to make decisions voluntarily without prejudice. Forcing decisions upon patients due to a conflict of interest is unethical and immoral (the only place where this country seems to allow this in healthcare is when the conflict of interest involves someone imposing pregnancy on a woman because the provider does not approve of abortion/contraception). There are ways to avoid these conflicting interests, it is the responsibility of the healthcare provider to avoid them if they stand in the way of the provider being able to treat a patient without prejudice.

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